The Pennsylvania Insurance Department says HealthAmerica has agreed to reprocess and pay some claims it had denied for emergency treatments.
Pennsylvania law requires health insurers to apply a reasonable standard for medical necessity when determining the need for emergency room care, even if it later turns out the care was not necessary, the department said in announcing the agreement with HealthAmerica, Harrisburg, Pa., a unit of Coventry Health Care Inc., Bethesda, Md..
The department had accused HealthAmerica of using standards that were too high in denying certain claims for emergency services.
“If you have chest pains and suspect you are having a heart attack, but the emergency room physician diagnoses indigestion, your insurance should still cover the emergency room visit,” state Insurance Commissioner Joel Ario said.
Ario’s department worked with the Pennsylvania Office of Attorney General to take action against HealthAmerica and its subsidiary HealthAssurance, for denying emergency room claims for more than 600 health plan members.
Commenting on the agreement, HealthAmerica said it cooperated fully with the Department of Insurance in reviewing its past claims payments.
“For the 7-year period inclusive of 2001 through 2007, HealthAmerica received 1.7
million medical emergency claims,” the company said in a statement. “The Attorney General’s attorneys and staff determined that 631 would be eligible for reprocessing.”
HealthAmerica also said that, based on discussions with state officials, it has altered its emergency claims-paying guidelines to ensure that they meet state standards.
“As a good corporate citizen and in an effort to cooperate with the Attorney General, HealthAmerica agreed to reprocess these claims, although the company did not admit any wrongdoing,” the company stated.
The company also stated that “misuse of the emergency room” increases health care costs for everyone.